Background Routine IPU audits (November 2022) identified medication issues and numerous complicated management systems. In addition, there was an increase in process-related medicine incidents reported. A similar situation in 2018 resulted in increased governance for Zopiclone and communication of concerns resulting in increased staff anxiety. Our learning from Psychological Safety (Edmondson. The fearless organization: creating psychological safety in the workplace for learning, innovation and growth. 2019) encouraged a different approach to the same issue.

Aims To use a systems-based approach (Healthcare Improvement Scotland. Safe management and use of controlled drugs report. 2014; Komashie, Ward, Bashford, et al. BMJ Open. 2021; 11: e037667) to encourage engagement with IPU staff to raise concerns, be part of the decision making and integral to the solution to improve the safety of medicines processes.

Methods Nov. 2022 – Multidisciplinary group formed (all IPU registered nurses invited). Dec. 2022 – Three key workflows identified: schedule 3–5 medication governance arrangements, use of patients’ own medicines and induction support. Jan. 2023 – Sub-group proposals considered. Feb. and Mar. 2023 – Planning and implementation of new processes and initial audit work. May 2023 onwards – Evaluation and feedback.

Results Governance arrangements: process now covers all schedule 3–5 medicines (Healthcare Improvement Scotland, 2014). Audit (April 2023) identified need for improved recording in registers for additional details within registers – repeat audit (May 2023) provided assurance of safe process in place. Feedback from staff continues and staff have openly discussed trust within medicine management processes(Edmondson, 2019; Jackson. J Adv Nurs. 2023 May 10).

Using patients’ own medicines: the benefits outweighed any disadvantages (Crowther, Wanklyn, Johnson, et al. BMJ Support Palliat Care. 2013; 3:A50) and supported the organisation’s environmental sustainability ambitions. Pharmacy team role developed to include medicines reconciliation process, supporting consistency. Improved induction and support: staff feedback identified the need for enhanced pharmacy support and a clear and extended mentorship structure to ensure consistent messaging to all new staff.

Conclusion Current indications from audit and incident reporting suggests improvement. Opportunities have continued to engage with staff. A systems-based approach ‘not hindered by fear’ (Edmondson, 2019) has supported joint working between clinical, quality assurance and leadership teams to achieve safer practices.